MEDICAL HISTORY QUESTIONNAIRE Please answer all the questions below to the best of your ability. Our ability to help you is based, in part, upon the accuracy and completeness of your medical/ophthalmic history and description of symptoms. Name First Last Date Date Format: MM slash DD slash YYYY Date of Birth Date Format: MM slash DD slash YYYY How would you like us to address you?Home PhoneWork PhoneCell PhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security #Email OccupationEmployerHow did you hear of our office? Insurance plan Family member Internet Other OR referred by:May we send them a thank you note?Please list any members of your family who come to our office:Chief reason(s) for visit:Special visual demands (at work/sports/hobbies):Are you interested in getting new eyeglasses today?Preliminary Medical HistoryDo you have any allergies to medications?YesNoExplain:Please list major injuries and/or surgeries you have had: Who is your primary care physician (internist/family doctor)?Are you pregnant and/or nursing?YesNoPlease note any personal or FAMILY HISTORY (parents or siblings only; living or deceased) with the following:NoSelfParentSiblingsUncertainCataractCrossed EyesGlaucomaMacular DegenerationRetinal Detachment/diseaseOtherIf other, please specify:Social History:Do you drive?YesNoHave you had visual difficulty when driving?YesNoDo you use tobacco products?YesNoHow long?Review of SystemsDo you currently or have you ever had any problems in the following areas:YesNoUncertainFever, Weight Loss/ GainIntegumentary (skin)HeadachesMigrainesLoss of VisionDouble visionDrynessItchingExcess tearingInfection of eye lidChalazion/ styeFlashes/FloatersThyroid DiseaseDiabetesPsychiatricLupus/other autoimmuneAllergies / Hay feverDry throat and/or mouthAsthmaCOPD / breathing problemHigh Blood PressureOther vascular diseaseRheumatoid ArthritisJoint PainAnemiaBleeding ProblemsCancerOtherIf cancer, please specify: Type Status If other, please specify:For ‘Yes’ answers to any of the above or if you have a condition not listed, please explain.List all drugs you are taking including aspirin, oral contraceptives, hormones, over the counter meds or vitamins: Maintaining the privacy of your information is of paramount importance to us as it helps foster confidence, good will and stronger relationships with you, our patients. If, at any time, you have questions or concerns about our privacy practices, please feel free to read our Notice of Privacy Practices. If you have any questions, please feel free to contact us at frontdesk@madisoneyesnj.com. Copies of this Notice are also available upon request.By initialing your name, you agree that you understand our Notice of Privacy Practices/HIPPAI have carefully completed this questionnaire to the best of my ability. I understand that my doctor’s ability to best care for me (or child) is based significantly on the family/personal health history and description of symptoms.Patient/Guardian SignatureDate Date Format: MM slash DD slash YYYY Doctor’s Signature (after reviewing)Date Date Format: MM slash DD slash YYYY Optos Ultra-Wide Retinal ImagingWe recommend retinal screening as part of a wellness exam for these reasons: We are able to safely and comfortably examine the interior of your eyes without using dilating eye drops. We are able to detect eye diseases at an early stage, even before the onset of symptoms. It is much faster than a dilated exam without the annoyance of eye drops or an extended exam with especially bright instrument lights. There isn't blurred or light sensitive vision afterwards. We maintain permanent images to identify change. We are able to detect and manage eye diseases with documentation of change or stability. While the instrument is expensive, we are able to keep the screening fee affordable at $39.Patient Name: First Last Signature:Date: Date Format: MM slash DD slash YYYY Please initial your selection below. Additional answers to frequently asked questions are available.InitialYes, please include the retinal imaging as part of my (or my child's) exam. I understand that there is a fee of $39 that is not covered by my insurance plan.InitialNo, I prefer to omit the retinal screening.InitialI prefer to have my eyes dilated.
